Gartner says Clinically Enhanced Risk Algorithms Drive Value

White Paper

Arcadia Principal Data Scientist Michael Simon, PhD, using content from Gartner analyst Laura Craft, has created a report that dives into algorithms in value-based care. A specific focus was how Electronic Health Record (EHR) data could be used to enhance traditional risk adjustment algorithms.

Highlights from the report:

  • “The new paradigm of care delivery is changing core business, clinical and operational processes, and the relationship with consumers and patients. Gartner asserts that the shift to value-based care delivery represents a radical change to the way these functions are thought of and carried out, and in the way providers conduct all aspects of their clinical and operational activities.”
  • “Healthcare is on the path to becoming an algorithmic business, as the use of advanced analytics models will transform the delivery of care. CIOs should use this research to understand the types of algorithms currently used and their specific challenges and value.”
  • “Inaccurate CMS-HCC risk reporting has broad negative effects: Under-reported risk leads to lost premiums for Medicare Advantage plans, and under-documented or too-aggressively reported risk increases exposure to time-consuming audits and potentially costly penalties.”
  • “Using EHR data can also help an organization avoid triggering an audit in situations where coding on a claim is not substantiated by clinical records within the EHR. Given the increased federal focus on auditing and accountability, Medicare Advantage organizations need to protect themselves from inadvertent over-coding.”

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February 14, 2017

Read more about Clinically Enhanced Risk

Use EHR data to improve HCC measurement and risk adjustment for Medicare, Medicaid, and commercial contracts. The traditional approach to risk adjustment uses claims-based data, but this approach to calculating clinical risk is deficient – and it can put an organization at financial risk.  Claims-based information is incomplete, slow, misaligned with provider data, and often not relevant at the point of care.   Luckily, EHR data can close the gaps.

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